BRONCHOPNEUMONIA

PREPARED BY: BSN-3B-0

NURSING HEALTH
HISTORY
I. IDENTIFYING INFORMATION
 The client's name is RP. He is 4 months
old, male, and Filipino. He was born on
March 17, 2011. He and his family
reside in Sampaloc, Paranaque. He is
the only child of Mr. & Mrs. P. He was
already baptized as an Adventist.These
data were gathered last August 5, 2011
at Parañaque Cmmunity Hospital/
Florencio Bernabe Hospital.
II. CHIEF COMPLAINT
 "Nahihirapan siyang huminga" as
verbalized by the mother of the client.
 Medical Diagnosis: Bronchopneumonia

 III.
Present Illness
2 weeks prior to admission, the patient
experience high grade fever. Then,hours
before prior to admission, his mother sought
that his child is having phlegm & difficulty of
breathing.
IV. PAST ILLNESS
 His mother claimed that this is his first
hospitalization. When the patient is sick, they are
consulting Dra. Carlita at the nearest health
center.
 V. Birth History
 Prenatal
RP is the only child of his parents. During
pregnancy period of his mother, she consults Dra.
Clarita to the health center that’s near to their
house. Her mother doesn’t experience any
complications during her pregnancy with RP. She
is taking Ferrous Sulfate one tab once a day,
usually every morning.
 Natal
 He was born 40 weeks of gestation, cephalic
presentation with Normal Spontaneous Delivery
at the hospital in Leyte. She delivered RP
without any difficulty or complications.
 Post Natal

 RP receive complete doses of BCG, DPT, OPV

& heap vaccines. She breastfed RP until 2
months old then she introduced formula milk
after that. At the present, the patient’s milk is
Bona. RP is taking Tiki-tiki drops once a day
every morning.
A. ERIKSON'S THEORY OF PSYCHOSOCIAL
DEVELOPMENT
EGO DEVELOPMENT OUTCOME: TRUST VS.
MISTRUST
BASIC STRENGTH: DRIVE AND HOPE
 Erikson also referred to infancy as the Oral
Sensory Stage (as anyone might who watches a
baby put everything in her mouth) where the major
emphasis is on the mother's positive and loving
care for the child, with a big emphasis on visual
contact and touch. If we pass successfully through
this period of life, we will learn to trust that life is
basically
 okay and have basic confidence in the future. If we
fail to experience trust and are constantly frustrated
because our needs are not met, we may end up with
a deep-seated feeling of worthlessness and
a mistrust of the world in general.
 Incidentally, many studies of suicides and
suicide attempts point to the importance of the early
years in developing the basic belief that the world is
trustworthy and that every individual has a right to
be here.
 Not surprisingly, the most significant relationship
is with the maternal parent, or whoever is our most
significant and constant caregiver.
 Analysis:
 In relation to the patient, her mother
claimed that RP is very attached to her. RP is
searching for his mother all the time. He can
smell that is his mother.
B. PSYCHOSEXUAL DEVELOPMENT (SIGMUND
FREUD)
 During the oral stage, the infant's primary source
of interaction occurs through the mouth, so the
rooting and sucking reflex is especially important.
The mouth is vital for eating, and the infant derives
pleasure from oral stimulation through gratifying
activities such as tasting and sucking. Because
the infant is entirely dependent upon caretakers
(who are responsible for feeding the child), the
infant also develops a sense of trust and comfort
through this oral stimulation.
 The primary conflict at this stage is the weaning
process--the child must become less
dependent upon caretakers. If fixation occurs
at this stage, Freud believed the individual
would have issues with dependency or
aggression. Oral fixation can result in problems
with drinking, eating, smoking or nail biting.
 Analysis:

 In relation to the patient, her mother

claimed that RP is always sucking his thumb
and his pacifier.
C. COGNITIVE DEVELOPMENT
 In this stage, it differentiates self from objects. It
recognizes self as agent of action and begins to
act intentionally: e.g. pulls a string to set mobile in
motion or shakes a rattle to make a
noise. Achieves object permanence: realizes that
things continue to exist even when no longer
present to the sense (pace Bishop Berkeley)

Analysis:
 The patient sees and distinguishes different
objects by their colors. He is reaching one object
to touch even though he can’t touch it.
D. ELIMINATION

 Usually the patient defecate once a day with

yellowish in color, hard stool and scanty in
amount. He urinates 2-3 times a day, yellowish
in color, scanty in amount.
E. SLEEP & ACTIVITY

 The patient is sleeping most of the time. He

usually sleeps at 8pm & wakes up 8 in the
morning. He takes a nap every now and then
while he is having bottle-fed.
F. NUTRITION

 The patient is not yet introduced solid foods

because he is only 4 months old. His milk is
Bona. She can finish 3-4 bottles of milk
everyday.
IX. FAMILY HEALTH HISTORY

 There’s no hederofamilial disease on the both

sides of their family.
GENOGRAM
 PHYSICAL
ASSESSMENT
GENERAL APPEARANCE

 Patient has a small body frame. No obvious

physical deformity. Patient weighs 6.1 kg and
has a length of 22’’ (55.8 cm). Head =16’’,
Chest =15’’, Abdomen=14”.
 BP 

 TEMP 

 RR

 PR 
SKIN

 Normal in racial tone of white complexion,

warm to touch and dry skin. No lesions in upper
extremity, as well as the lower extremities. Hair
is evenly distributed, no bruises or birth marks.
HAIR

 Hair is black in color and thick and evenly

distributed. The scalp has no presence of
vernix caseosa. Hair is not evenly distributed.
HEAD AND FACE

 Head is appropriate to her body size.

(Head=16). Anterior and posterior fontanels are
open. Fontanel is sunken. No obvious physical
deformity.
EYES

 The eyes are straight normal. Cornea is covered

with a thin white tissue. Bulbar conjunctiva is
pink while palberal is white. Lacrimal apparatus
is moist. Schlera is clear.
EAR

 Ear is within normal racial tone. It is symmetric

in size and position. Pinna recoils when folded
and very few cerumen found at external canal.
Patient turns his head when sound is
produced.
NOSE

 Nose is normal in racial tone, the septum is

at midline. Discharges are present on the nares
of the patient and experiencing difficulty of
breathing. Mucosa is pink and clear without
any lesions. Sinuses are not palpable.
MOUTH

 Lips are pale and mucosa is dry. Tongue is

at the midline. No teeth yet. Gums are pink and
the soft and hard palate as well. Both palates
are palpable. Frenulum is at the midline. Has a
good sucking reflex.
PHARYNX

 Uvula is at the midline, mucosa is pink in

color. Tonsils are not inflamed. Posterior
pharynx is not congested. Gag reflex is present.
NECK

 Neck muscles are equal in size, muscle

strength is good. Lymph nodes are not
palpable. The trachea is in the midline.
BREAST AND AXILLA

 No palpable lymph nodes.

 Chest and Lungs

Chest has an edema. False ribs are
prominent upon observation. Breath sounds are
decreased on bronchi upon auscultation.
Wheezes were heard even without auscultating
ABDOMEN

 Abdomen is rounded in contour and

symmetrical in posterior and anterior portion.
Skin is within normal racial tone which is
brown. There are no presence of lesions. Liver
is not palpable. Bladder is not distented.
UPPER AND LOWER EXTREMITIES

 Motor strength on both upper and lower

extremities is good with the grade of 4/5. No
obvious physical deformities, peripheral pulses
are palpable.
 Genitalia

 Appearance is good and no deformities

noticed.
DIAGNOSTIC
PROCEDURE
CHEST PA

 -Chest X-ray is the most frequently requested

radiograph. This must be done after insertion
of chest tubes or subclavian catheters to
determine their anatomic position, as well as to
detect possible pneumothorax related to
insertion procedure.
 Indication:
 This is used to diagnosed cancer,
tuberculosis and other pulmonary diseases and
disorders of the mediastinum and bony thorax.
Name of the Date Ordered Normal Values Values Interpretation
Procedure (Standard) Obtained
(Result)
Chest PA July 17, 2011 Findings: Impression:
Coarse reticular Instertitial
densities are Pneumonitis ,
seen in the Bilateral
inner lung
zones. The
heart is not
enlarged. The
diaphragm,
sulci and bony
thorax are
unremarkable.
COMPLETE BLOOD COUNT

 -CBC is the basic screening test and one of the

most frequently ordered blood test. It includes
hemoglobin and hematocrit measurements, RBC
count, WBC counts, erythrocyte and RBC indices.
 Indication:
 It is indicated for severe dehydration and
shock, for acute massive blood loss and with
hemolytic reaction after transfusion of
incompatible blood with fluid overload. For severe
hemorrhage and anemia states, and also for
detecting presence of infection.
Name of the Date Ordered Normal Values Values Interpretation
Procedure (Standard) Obtained
(Result)

CBC July 16, 2011 Hemoglobin 11.6gm% LOW

14-17gm%

Hematocrit 35.0vol% LOW

42-51vol%
WBC 5,000- 8,500/cumm NORMAL
10,000cumm
Segmenters 57% NORMAL
55-65%
Lymphocytes 43% NORMAL
25-35%
Platelet Count 240,000 NORMAL
150,000-
400,000
URINALYSIS

 -A test that determines the content of the urine.

Because urine toxins and excess fluids from the
body, it can contain important clues. Urinalysis can
be used to detect some types of disease,
particularly in the case of metabolic disorder and
kidney disease.
 Indication
 It is used to detect the presence of UTI,
protenuria , glucosuria, ketonuria, presence of
urinary sediments which indicates renal pathology.
Name of the Date Normal Values Values Obtained Interpretation
Procedure Ordered (Standard) (Result)

Urinalysis July 27, Color Clear/acidic Lt. Yellow

2011

Transparency Sl.Cloudy clear

Reaction 4.6-7.5 Ph 6.0
Sp gravity 1.918-1.025 1.012
Sugar negative negative
Protein negative negative
Microscopic
RBC 0-1/hpf 0.1
Puscell 1-3/hpf 0.2
Bacteria Few Few
Epithelial Rare Few
ANATOMY &
PHYSIOLOGY
RESPIRATORY SYSTEM
 Nose and Nasal Cavity. The nose is the
uppermost part of the respiratory tract. It is
made up to two bones and cartilage. It forms a
hollow passage that connects the nostrils and
the top of the throat. This passage is called the
nasal cavity. It is lined with a mucous membrane
which bears tiny hairs. The function of the nose
is to filter, warm and moisten the air before it
moves on to other parts of the respiratory tract.
The tiny hairs trap the dust particles, bacteria
and other foreign bodies that enter the nose.
These hairs also induce sneezing to remove
foreign bodies lodged in the nose.
 Mouth and Pharynx. Face a mirror and open
your mouth. Do you see the arch at the black
part of your mouth? This arch leads into your
pharynx, or throat. The pharynx is a
passageway from the back of the mouth and
nose to the upper part of the esophagus and
into the voice box, or larynx. The pharynx acts
like a station where the food tube and the air
tube meet. Food beings swallowed is prevented
from entering the air tube by a thin structure,
called epiglottis, that closes the air tube. This is
why you cannot breathe while you are
swallowing.
 Larynx and Trachea. At the lower end of the
pharynx is the larynx which forms part of the air
tube. It is made of cartilage. One of its functions is
production of voice. It does this with the help of
either one of two pairs of vocal cords. When air
from the lungs passes over the stretched vocal
cords, vibrations are produced. The tongue palate
and lips modify the vibrations to produce speech.
Another function of the larynx is to prevent
choking. The elongated space between the vocal
cords is called glottis. As mentioned earlier, the
epiglottis folds back over the glottis when you
swallow food, so the food cannot enter the trachea
or air tube.

 The trachea, or windpipe, begins just below the
larynx and ends behind the upper part of the
breastbone where it divides to form two tubes. The
trachea is made of elastic tissue and smooth
muscle. It also has rings of elastic cartilage that
keep the trachea open when the neck moves. It is
lined with a mucous membrane and hair like
projections called cilia. Mucus helps trap dust and
bacteria in the incoming air. The cilia move the
mucus upward to clear the respiratory tract.
 The Lungs. We have two lungs. They lie in the
chest cavity and are surrounded by the rib cage.
Each lung is enclosed in the double membrane
called the pleura. The pleurae are coated by fluid.
This allows the lungs to slide freely as they expand
and contract during breathing. The right lung has
three lobes while the left lung has two. Each lobe
has its own bronchi, bronchioles and blood
vessels. The lungs are the main organs of the
respiratory system. Their function is to supply the
body with oxygen and remove carbon dioxide from
the blood.

PRIORITIZED
NURSING
DIAGNOSIS
TREATMENT

 1. Intravenous fluid Therapy
 Is the giving of liquid substance directly into a vein. It is the
fastest way to deliver fluids and medications throughout the
body.

 Nursing Responsibilities:
 ·Assess for any inflammation or infiltration
 ·Compute for the slow rate required for the patient
 ·Use alcohol swab when putting medication throughout bolus

 IV ordered:
 D51MB500x25cc/hr
 2. Suctioning
 Is the removal of material through the
use of negative pressure, as in suctioning an
operative wound during and after surgery to
remove exudates, or suctioning of the
respiratory passages to remove secretions that
the patient cannot remove by coughing.
Suctioning of the nose and mouth is a relatively
simple procedure requiring only cleanliness
and sensible care in the removal of liquids
obstructing the nasal and oral passages.

 Nursing Responsibilities:

 PRE-
 Determine need for suctioning. Administer pain
medication before suctioning to postoperative
patient.
 Explain procedure to patient.
 Assemble equipment.
 Perform hand hygiene.
 Adjust bed to comfortable working position. Lower
side rail closet to you. Place patient in a semi-
Fowler’s position if he or she is conscious. Place
towel or waterproof pad across patient’s chest.
 Turn suction to appropriate pressure.
 During-
 Gently insert catheter with suction off by leaving
the vent on the Y-connector open. Slip catheter
gently along the floor of an unobstructed nostril
toward trachea to suction the nasopharynx. Or
insert catheter along side of mouth toward
trachea to suction the oropharynx. Never apply
suction as catheter is introduced.
 Apply suction by according suctioning port with
your thumb. Gently rotate catheter as it is being
withdraw. Do not allow suctioning to continue for
more than 10 to 15 seconds at a time.
 Flush the catheter with saline and repeat
suctioning as needed and according to
patient’s toleration of the procedure.
 Allow at least a 20- to 30-second interval if
additional suctioning is needed. The nares
should be alternated when repeated suctioning
required. Do not force the catheter through the
nares. Encourage patient to cough and breathe
deeply between suctioning.
 POST-
 When suctioning is completed, remove gloves inside out
and dispose of gloves, catheter, and container with
solution in proper receptacle. Perform hand hygiene.
 Use auscultation to listen to chest and breath sounds to
assess effectiveness of suctioning.
 Record time of suctioning and nature and amount of
secretions. Also note the character of the patient’s
respirations before and after suctioning.
 Offer oral hygiene after suctioning.
 Physician Ordered:
 Suction secretion if PR increase


 2. Oxygen Saturation/ Therapy

 Oxygen may be classified as an element, a
gas, and a drug. Oxygen therapy is the
administration of oxygen at concentrations
greater than that in room air to treat or
prevent hypoxemia (not enough oxygen in the
blood). Oxygen delivery systems are classified
as stationary, portable, or ambulatory. Oxygen
can be administered by nasal cannula, mask,
and tent. Hyperbaric oxygen therapy involves
placing the patient in an airtight chamber with
oxygen under pressure.

 Nursing Responsibilities:


 PRE-
 Asses for the signs and symptoms of hypoxia

 Place cautionary signs reading “No Smoking:

Oxygen in use” on the clients door, at the foot or
head of the bed, and on the oxygen equipment.
 Ensure equipment is functioning correctly at
beginning of each shift.
 Patients requiring oxygen therapy should have
their oxygen saturation checked with a pulse
oximeter continuously.
 During-
 Place the oxygen mask and secure it tightly
 Every 30 minutes: visual check. Note
respiratory rate and effort; SpO2; nausea and
vomiting .Hourly: pulse rate and rhythm; blood
pressure;
 Every two hours: condition of skin around and
under mask and rubber securing band.

 POST-
 Document condition and interventions; condition of
conjunctivae, condition of skin presence of nausea and
vomiting.

 Every four hours: palpate abdomen for distension and

assess need for stomach decompression. Auscultate
lungs for equal air entry.

 Every four hours: palpate abdomen for distension and

assess need for stomach decompression. Auscultate
lungs for equal air entry.
 Physician ordered:
 Refer oxygen saturation if 80’s RR increase
 DIET:
 The physician orders the patient in NPO

 EXERCISE:
None

 Nursing Management:

 For close watch

 Referred to ophthalmologist
 Suction secretion if PR increase
 Refer oxygen saturation if 80’s RR increase
 Carbon dioxide at 2-3 LPM if RR increase 88cpm
 CLIENT’S DAILY PROGRESS CHART

Date Diagnostic Diet Activity Medication Treatment

Procedure
July 16, CBC, NPO None Salbutamol IV fluid,
2011 Urinalysis Suctioning
Oxygen
Saturation/
Therapy
July 17, Chest PA NPO None Salbutamol IV fluid,
2011 Suctioning
Oxygen
Saturation/
Therapy
July 18, None NPO None Salbutamol IV fluid,
2011 Suctioning
Oxygen
Saturation/
Therapy
EVALUATION
 Narrative Evaluation
 After 8 hours of nursing intervention the
client had a patent/ clear airway, no
difficulty of breathing and have effective
breathing pattern.
 Medication

 Salbutamol, Cefuroxime, Hydrocortisol

 Exercise

 None
 Treatment
 Continue use of nebulizer when client have
difficulty of breathing
 Health teaching
 For the mother, stay always at the sde of the
client and monitor status of the client every 2hrs
 Out Patient Department
 2 weeks after the client was discharge, the
client should be brought to PCH for follow-up
check up
 Diet
 The client is still an infant. Liquefied
substances specifically milk should be given